Context: Extracorporeal shock wave lithotripsy (SWL) and ureteroscopy
(URS), with or without intracorporeal lithotripsy, are the most common
treatments for upper ureteric stones. With advances in technology, it is
unclear which treatment is most effective and/or safest.
Objective: To systematically review literature reporting benefits and
harms of SWL and URS in the management of upper ureteric stones.
Evidence acquisition: Databases including Medline, Embase, and the
Cochrane library were searched from January 2000 to November 2014. All
randomised controlled trials (RCTs), quasi-randomised controlled trials,
and nonrandomised studies comparing any subtype or variation of URS and
SWL were included. The primary benefit outcome was stone-free rate
(SFR). The primary harm outcome was complications. Secondary outcomes
included retreatment rate, need for secondary, and/or adjunctive
procedures. The Cochrane risk of bias tool was used to assess RCTs, and
an extended version was used to assess nonrandomised studies. Grading of
Recommendations Assessment, Development, and Evaluation was used to
assess the quality of evidence.
Evidence synthesis: Five thousand-three hundred and eighty abstracts and
387 full-text articles were screened. Forty-seven studies met inclusion
criteria; 19 (39.6%) were RCTs. No studies on children met inclusion
criteria. URS and SWL were compared in 22 studies (4 RCTs, 1
quasi-randomised controlled trial, and 17 nonrandomised studies).
Meta-analyses were inappropriate due to data heterogeneity. SFR favoured
URS in 9/22 studies. Retreatment rates were higher for SWL compared with
URS in all studies but one. Longer hospital stay and adjunctive
procedures (most commonly the insertion of a JJ stent) were more common
when primary treatment was URS. Complications were reported in 11 out of
22 studies. In eight studies, it was possible to report this as a
Clavien-Dindo Grade. Higher complication rates across all grades were
reported for URS compared with SWL. For intragroup (intra-SWL and
intra-URS) comparative studies, 25 met the inclusion criteria. These
studies varied greatly in outcomes measured with data being
heterogeneous.
Conclusions: Compared with SWL, URS was associated with a significantly
greater SFR up to 4 wk but the difference was not significant at 3 mo in
the included studies. URS was associated with fewer retreatments and
need for secondary procedures, but with a higher need for adjunctive
procedures, greater complication rates, and longer hospital stay.
Patient summary: In this paper, the relative benefits and harms of the
two most commonly offered treatment options for urinary stones located
in the upper ureter were reviewed. We found that both treatments are
safe and effective options that should be offered based on individual
patient circumstances and preferences. (C) 2017 European Association of
Urology. Published by Elsevier B.V. All rights reserved